Malignancy in Medicine

[Publicola]

During my medical training I have realized that there is a wide variety of people who you train with. Some are nice and some are mean. Nice people take the time to teach you and challenge you but do not crush you. Mean people are generally hostile, bossy, take the opportunity to torture you with excess work. Unfortunately, what is often lost in this game of medicine is the patient. Are we not there to serve patients a nice teacher may say...I suspect the mean ones are at work to spoon feed their egos and uphold the malignant status quo that is so prevalent in medicine. The field that advocates "first do no harm" is the very same field that pushes people to their physical limits with long 30 hours shifts and puts the safety of patients in question. I very much doubt their are many physicians who would allow themselves to be cared for by an intern at the 24th hour of their shift. So if this is true why do we then continue to have people work these long shifts? The answer lies somewhere between the fact that doctors need so patient encounter so be proficient and a rather crude "I trained like that and I take care of patients so you should train in the same manner". Many fields pride themselves in algorithms to tell them how to treat patients, where does a sleep deprived intern fit into the good care algorithm? It seems that at a certain point the practice of medicine for our "mean supervisors" is less about the patient (who is supposed to be the reason for our coming to work) and more about them. Long ago pride was recognized as one of the seven deadly sins....

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[WholeLottaGame7]

During my medical training I have realized that there is a wide variety of people who you train with. Some are nice and some are mean. Nice people take the time to teach you and challenge you but do not crush you. Mean people are generally hostile, bossy, take the opportunity to torture you with excess work. Unfortunately, what is often lost in this game of medicine is the patient. Are we not there to serve patients a nice teacher may say...I suspect the mean ones are at work to spoon feed their egos and uphold the malignant status quo that is so prevalent in medicine. The field that advocates "first do no harm" is the very same field that pushes people to their physical limits with long 30 hours shifts and puts the safety of patients in question. I very much doubt their are many physicians who would allow themselves to be cared for by an intern at the 24th hour of their shift. So if this is true why do we then continue to have people work these long shifts? The answer lies somewhere between the fact that doctors need so patient encounter so be proficient and a rather crude "I trained like that and I take care of patients so you should train in the same manner". Many fields pride themselves in algorithms to tell them how to treat patients, where does a sleep deprived intern fit into the good care algorithm? It seems that at a certain point the practice of medicine for our "mean supervisors" is less about the patient (who is supposed to be the reason for our coming to work) and more about them. Long ago pride was recognized as one of the seven deadly sins....

Haha, feel better now that that's off your chest? You are preaching to the choir, my friend.

Though the deeper I get into my medical education, the more I'm starting to appreciate the danger of more patient hand-offs.

The question is, is there a happy medium to be found?

 

[DarthNeurology]

During my medical training I have realized that there is a wide variety of people who you train with. Mean people are generally hostile, bossy, take the opportunity to torture you with excess work. Unfortunately, what is often lost in this game of medicine is the patient. The field that advocates "first do no harm" is the very same field that pushes people to their physical limits with long 30 hours shifts and puts the safety of patients in question.

I think you raise two issues here:

1. There are a lot of "mean" people in medicine, or looked at from another perspective, medicine tolerates a lot of abuse of subordinates. Of course this detracts from patient care, but on many services you will spend a large amount of your time trying to placate abusive attendings over taking time for patient care.

2. Residents work 30 hours. Not so bad compared to 36 plus hour work days in the "good ole days". Personally, if you do 30 hours with good people the work is manageable, so I don't think that the amount of time is that bad.

3. Fatigued residents taking care of patients. If a resident is up 24 hours, yes there is some fatigue, however the alternative would be handing off patients every 12 hours? Increased hand offs also mean increased errors and having an intern that knows a patient front and back although up for 24+ hours is better than a fresh intern that knows nothing about the patient in some cases.

 

[exPCM]

I think you raise two issues here:

2. Residents work 30 hours. Not so bad compared to 36 plus hour work days in the "good ole days". Personally, if you do 30 hours with good people the work is manageable, so I don't think that the amount of time is that bad.

3. Fatigued residents taking care of patients. If a resident is up 24 hours, yes there is some fatigue, however the alternative would be handing off patients every 12 hours? Increased hand offs also mean increased errors and having an intern that knows a patient front and back although up for 24+ hours is better than a fresh intern that knows nothing about the patient in some cases.

That is straight out propaganda from the PD playbook.
Here is the reality:
1. Human physiology does not mesh with staying awake for 30 consecutive hours.
2. There are many hospitals that give good care that do not have any residents and where the attendings don't work 30 hours straight. Handoffs happen and all this stuff about knowing the patient "front and back" is overrated. The length of stays in hospitals are much shorter and the patient turnover is so much higher than in the past that hospitalists and residents often just deal with acute issues but do not get to know any patients "front and back".

 

[.edu-MD]

Increased hand offs also mean increased errors

I hear this statement a lot but I wonder two things:
(1) Is it true?
(2) Does it have to be that way?

(1) Imagine a general medical floor in a hospital without residents. Imagine they staff two 12-hour shifts of hospitalists from 6a-6p and then 6p-6a. If a patient stays any more than 12 hours, each shift will have seen the patient once. Each extra day the patient stays, each shift will see that patient yet again. So the claim that any shift won't know the patient doesn't really work for me. In the end, you have a situation where 2 people (one per shift) have the opportunity to know the patient equally well but neither is working more than 12 hours straight and thus should not be sleep-deprived (at least not from working that particular job).

(2) Since it is becoming quite popular now to use a 7 on 7 off (with 12 hour shifts) hospitalist staffing model, especially in community hospitals, handoffs are commonplace. If they are such a big problem, residencies should be providing appropriate training and practice before we get out into the real world, shouldn't they? Or would we need to create a fellowship to learn that skill?

A further thought experiment. If my patient load = 1 during the day, I would expect I could be trained to give a good handoff to my night counterpart. Even at a patient load of 2 or 3, I expect I could give a good handoff. So at what point do my handoffs start suffering (and how do you measure that)? Whatever that point is would make a nice evidence-based cap.

 

[McGillGrad]

There are studies that conclude that hand-off's cause errors. This is not something Darthneurology is making up.

 

[WhoisJohnGalt]

There are studies that conclude that hand-off's cause errors. This is not something Darthneurology is making up.

There are studies that conclude that sleep deprivation causes errors. This is not something that anyone else is making up.

 

[McGillGrad]

There are studies that conclude that sleep deprivation causes errors. This is not something that anyone else is making up.

As in all peer-reviewed research, this was factored in to the conclusion. Your point is well taken but irrelevant, nonetheless.

 

[.edu-MD]

There are studies that conclude that hand-off's cause errors. This is not something Darthneurology is making up.

I realize he's not making it up. It was just that I hear it thrown out a lot and wonder if it's just an easy reason hospital administrators try to use to keep residents working long hours. After all, they have a lot to lose financially if they have to diminish their use of residents. As WhoisJohnGalt said, sleep deprivation also causes errors.

This leads to the question of which causes worse errors? And for which, if at all, of the two situations can better training help diminish the bad errors.

 

[elwademd]

I hear this statement a lot but I wonder two things:
(1) Is it true?
(2) Does it have to be that way?

(1) Imagine a general medical floor in a hospital without residents. Imagine they staff two 12-hour shifts of hospitalists from 6a-6p and then 6p-6a. If a patient stays any more than 12 hours, each shift will have seen the patient once. Each extra day the patient stays, each shift will see that patient yet again. So the claim that any shift won't know the patient doesn't really work for me. In the end, you have a situation where 2 people (one per shift) have the opportunity to know the patient equally well but neither is working more than 12 hours straight and thus should not be sleep-deprived (at least not from working that particular job).

(2) Since it is becoming quite popular now to use a 7 on 7 off (with 12 hour shifts) hospitalist staffing model, especially in community hospitals, handoffs are commonplace. If they are such a big problem, residencies should be providing appropriate training and practice before we get out into the real world, shouldn't they? Or would we need to create a fellowship to learn that skill?

A further thought experiment. If my patient load = 1 during the day, I would expect I could be trained to give a good handoff to my night counterpart. Even at a patient load of 2 or 3, I expect I could give a good handoff. So at what point do my handoffs start suffering (and how do you measure that)? Whatever that point is would make a nice evidence-based cap.

you're assuming the night person is rounding on patients. typically, people at night (whether residency or as an attending) are doing admissions, responding to emergencies, and answering calls/pages. so, if the first two nights nothing happens with patient a, the night person may not know a whole lot about patient a if something goes wrong on the 3rd night (as patient a was never seen by that doc).

with that being said, there has been some clamoring for medical schools/residencies to help train on how to do an appropriate sign out.

i think that, in part, some of it comes with experience. in other words, learning how to give someone an appropriate and efficient hand off- in the end, if you're getting a sign out, all you truly want to know is:

1. who is the patient?
2. why are they here?
3. what are we doing for them?

 

[DarthNeurology]

That is straight out propaganda from the PD playbook.
Here is the reality:
1. Human physiology does not mesh with staying awake for 30 consecutive hours.
2. There are many hospitals that give good care that do not have any residents and where the attendings don't work 30 hours straight. Handoffs happen and all this stuff about knowing the patient "front and back" is overrated. The length of stays in hospitals are much shorter and the patient turnover is so much higher than in the past that hospitalists and residents often just deal with acute issues but do not get to know any patients "front and back".

Wow, I never thought that something I said would be considered to be straight out of the "PD playbook."

Since you say you are an attending then you most likely did 36+ hour shifts, anyway I have done 36+ hour shifts on rotations and after that 30 hours is a breeze.

Academic centers usually have better scores in terms of health care grading than big private centers, so maybe having residents around is a good thing? Plus, private attendings often work long shifts, and can often work a longer 80 hour work week.

 

[Winged Scapula]

Wow, I never thought that something I said would be considered to be straight out of the "PD playbook."

Resistance is futile.

You will be assimilated.

 

[DarthNeurology]

Increased hand offs also mean increased errors

I hear this statement a lot but I wonder two things:
(1) Is it true?
(2) Does it have to be that way?

I had trouble following your post, but I think that you are responding to my whole post, not my comment about hand offs.

Hand-offs aren't perfect, i.e. there is an error rate, let's say that the error rate is 3 percent of handoffs have a major mistake, and perhaps 5 percent of hands offs have a minor mistake. This is just human nature as errors do happen, especially when information is transferred, remember the "telephone game" as a kid where the rumor changes as it circulates?

Anyway, it is obvious that an increased number of handoffs will increase the number of mistakes made. A certain percentage of these mistakes will have a clinical significance perhaps even death. If the nation as a whole increases the handoffs in IM departments by two then yes you will have significant effects.

Of course there maybe a set of things pushing up mistakes and something else pushing it down, for example a lack of sleep may increase errors as well. So you in the end might have the benefits of decreased handoffs and better patient knowledge when compared to better rested resident to take care of patients. Which way is best? Who knows, too many variables, this why trials are done.

 

[gutonc]

i think that, in part, some of it comes with experience. in other words, learning how to give someone an appropriate and efficient hand off- in the end, if you're getting a sign out, all you truly want to know is:

1. who is the patient?
2. why are they here?
3. what are we doing for them?

4. What do I need to follow-up on/expect from them tonight?

A corollary to that is the "if/then" issue. You can certainly ask me to follow-up on their 2200 CBC but what am I looking for and what do you want me to do about it? Sure, I can probably figure it out, but if you have a plan, I would like to hear about it so we can present a united front and manage the patient together.

When I take sign-out while moonlighting, I basically want to know what everyone is in for, what needs to be followed up on tonight and who is fixin' to die. That will almost always get me through the night with minimal drama.

 

[exPCM]

Wow, I never thought that something I said would be considered to be straight out of the "PD playbook."

Since you say you are an attending then you most likely did 36+ hour shifts, anyway I have done 36+ hour shifts on rotations and after that 30 hours is a breeze.

Academic centers usually have better scores in terms of health care grading than big private centers, so maybe having residents around is a good thing? Plus, private attendings often work long shifts, and can often work a longer 80 hour work week.

Yes, I worked quite a few 36 hour shifts, often without sleep, during my prelim medicine year. I did not think it was humane and still don't.
If handoffs are so dangerous then why stop at 30 hours, why not 48 or 72 hour shifts?
The idea that academic med centers are better is not supported by evidence:
Hospitals where doctors receive training are generally thought of as the most advanced type of hospital. So, for the patient, is it best to be admitted to a 'teaching hospital'? A review of the evidence from international research has concluded that there is no strong evidence that patients in teaching hospitals do better - or worse - than those admitted to other hospitals.

http://www.medicalnewstoday.com/articles/51644.php

All of this BS that residents must suffer through long shifts without sleep to keep patients safe is ridiculous. The PD mantra is "the patient comes first". The implementation is that the resident is forced to work unhealthy and non-physiologic shifts. Hiring PAs to cover at night like some community hospitals do might cost money - however they don't want to do this at many teaching hospitals because it would cut into the bottom line.

Training programs routinely violate the law and abuse residents with no consequences.

During my internship, a colleague fell asleep at the wheel on the way home, as I often did secondary to my 90 to 105 hour work weeks. This time the colleague crossed the center line, had a head on collision, and ended up a quadriplegic.

Now I realize you probably don't give a flying leap about what happened to my colleague because it wasn't you. Many here will say that he is whining from his wheelchair. Why in the world did we become doctors in the first place? To abuse people?

 

[DarthNeurology]

Yes, I worked quite a few 36 hour shifts, often without sleep, during my prelim medicine year. I did not think it was humane and still don't.
If handoffs are so dangerous then why stop at 30 hours, why not 48 or 72 hour shifts?
The idea that academic med centers are better is not supported by evidence:
Hospitals where doctors receive training are generally thought of as the most advanced type of hospital. So, for the patient, is it best to be admitted to a 'teaching hospital'? A review of the evidence from international research has concluded that there is no strong evidence that patients in teaching hospitals do better - or worse - than those admitted to other hospitals.

http://www.medicalnewstoday.com/articles/51644.php

All of this BS that residents must suffer through long shifts without sleep to keep patients safe is ridiculous. The PD mantra is "the patient comes first". The implementation is that the resident is forced to work unhealthy and non-physiologic shifts. Hiring PAs to cover at night like some community hospitals do might cost money - however they don't want to do this at many teaching hospitals because it would cut into the bottom line.

Training programs routinely violate the law and abuse residents with no consequences.

During my internship, a colleague fell asleep at the wheel on the way home, as I often did secondary to my 90 to 105 hour work weeks. This time the colleague crossed the center line, had a head on collision, and ended up a quadriplegic.

Now I realize you probably don't give a flying leap about what happened to my colleague because it wasn't you. Many here will say that he is whining from his wheelchair. Why in the world did we become doctors in the first place? To abuse people?

Very interesting post. I had seen big academic centers listed as the best for certain specialty services and assumed that they are better, but I found a list on Health Grades of the 50 best hospitals, and Harvard affiliated hospitals aren't one of them!

Arizona
Mayo Clinic Hospital Phoenix
California
Cedars-Sinai Medical Center Los Angeles
Glendale Adventist Medical Center Glendale
Glendale Memorial Hospital & Health Center Glendale
Good Samaritan Hospital Los Angeles
Saint John’s Hospital Health Center Santa Monica
Colorado
Centura Health-Penrose Saint Francis Health Services Colorado Springs
Florida
Bay Medical Center Panama City
Central Florida Regional Hospital Sanford
Delray Medical Center Delray Beach
Holmes Regional Medical Center Melbourne
Lawnwood Regional Medical Center and Heart Institute Fort Pierce
Munroe Regional Medical Center Ocala
Ocala Regional Medical Center/West Marion Hospital Ocala
Palm Beach Gardens Medical Center Palm Beach Gardens
Sarasota Memorial Hospital Sarasota
Georgia
Saint Joseph's Hospital of Atlanta Atlanta
Illinois
Alexian Brothers Medical Center Elk Grove Village
Evanston Hospital Evanston
including: Highland Park Hospital Highland Park
Rush North Shore Medical Center Skokie
Indiana
The Community Hospital Munster
Kentucky
Baptist Hospital East Louisville
Jewish Hospital Louisville
including: Sts Mary & Elizabeth Hospital Louisville
St. Elizabeth Medical Center Edgewood
Michigan
Genesys Regional Medical Center Grand Blanc
Munson Medical Center Traverse City
William Beaumont Hospital Royal Oak
Missouri
St. Luke's Hospital Chesterfield
New Jersey
Hackensack University Medical Center Hackensack
Ohio
Akron General Medical Center Akron
Christ Hospital Cincinnati
Grandview and Southview Medical Centers Dayton
Hillcrest Hospital Mayfield Heights
Parma Community General Hospital Parma
St. John West Shore Hospital Westlake
Southwest General Health Center Middleburg Heights
Summa Health Systems Hospitals Akron
Pennsylvania
Easton Hospital Easton
Hamot Medical Center Erie
Lancaster General Hospital Lancaster
Lehigh Valley Hospital Allentown
Main Line Health - Lankenau Wynnewood
Mercy Hospital Scranton Scranton
St. Luke's Hospital Bethlehem
including: Horton St. Luke's Hospital-Allentown Campus Allentown
Tennessee
Memorial Healthcare System Chattanooga
Texas
CHRISTUS Santa Rosa Healthcare San Antonio
Rio Grande Regional Hospital McAllen
Virginia
Henrico Doctors' Hospital - Forest Richmond
including: Henrico Doctors' Hospital - Parham Richmond
Inova Fairfax Hospital Falls Church
Wisconsin
Aspirus Wausau Hospital Wausau

Of course it is sad that your friend became a quadriplegic after having an accident post call. Some studies have found that staying up for 24 hours plus is the same as being legally intoxicated (I think).

Fortunately things are improving, i.e. 30 hours is a lot less than the 36 to 38 hours that did happen in the past. But PDs don't consciously sit down and decide to screw over residents by making them work 80 hours a week as this decision has been automatically made for decades, i.e. it is just traditional in medicine to make people work this long. Plus attendings often work longer than 80 hours in their practice in later years as there are no restrictions on the hours than an attending can work.

In a way there are two sides to medicine:

1. Acting compassionately to care for the patient.

2. Setting up a survival of the fittest gladiator battle between students, residents and even fellows. In the eyes of the attending there is a *not* compassion for the subordinate who is felt to be inferior or whom protests his or her treatment. Say you work in a pet shop and are fired because you got in a fight with boss because he/she has a personality disorder or something. Are you going to say "But we take care of cute and cuddly kittens here! How could you do this to me!" Nope. Same thing in medicine, there isn't any culture of attendings caring for their students and residents like patients, far from it, subordinates are treated poorly to see who can survive. A lot of this started when Darwin's stuff hit the academic circuit in england IMHO, i.e. to week out students/residents, but it had been going on before too.

I *do* have compassion for your friend who became paralyzed, but many surgeons who work 30 plus hours in a row would conclude that he/she didn't rest enough on their time off. Some of my med school classmates would joke that the kid who chokes and dies on a marble via evolution won't produce offspring that choke and die on a marble.

Sad but true. I would study decreasing residency hours to less than 24 hours because of your friend and others, but many would not.

 

[Law2Doc]

I had trouble following your post, but I think that you are responding to my whole post, not my comment about hand offs.

Hand-offs aren't perfect, i.e. there is an error rate, let's say that the error rate is 3 percent of handoffs have a major mistake, and perhaps 5 percent of hands offs have a minor mistake. This is just human nature as errors do happen, especially when information is transferred, remember the "telephone game" as a kid where the rumor changes as it circulates?

Anyway, it is obvious that an increased number of handoffs will increase the number of mistakes made. A certain percentage of these mistakes will have a clinical significance perhaps even death. If the nation as a whole increases the handoffs in IM departments by two then yes you will have significant effects.

Of course there maybe a set of things pushing up mistakes and something else pushing it down, for example a lack of sleep may increase errors as well. So you in the end might have the benefits of decreased handoffs and better patient knowledge when compared to better rested resident to take care of patients. Which way is best? Who knows, too many variables, this why trials are done.

Speaking from personal experience, I'm a lot more dangerous to a patient when I don't know him/her because I've just been handed off a list of 40 patients and gotten maybe a sentence on each of them, largely consisting of "this person should be fine, there is nothing you really need to do for them tonight, just follow up on the labs", than I am at the end of a 30 hour shift. I've been in both situations many times this year and the patient is much much better off in the latter case. So honestly, I don't know if I'm a worse doctor at the beginning of the shift when I don't know squat about the patient, or at the end of the shift, when I'm a bit punchy from no sleep. But I feel like I have a fighting chance to give the right reflex answer at the end of the shift when somewhere in my groggy brain I know the patient.

I don't like long shifts and I like to be able to go to sleep in my own bed. But I'd be shocked if more frequent handoffs aren't significantly more dangerous to patient care than longer hours. Granted, I'm a terror on the road coming home after the 30 hour shift, and so there probably is some justification for shorter hours on that basis. But purely in terms of patient care, now that I've been down this path first-hand, I have to say that the patient is better off with me tired than with me ignorant of their issues. It's like the old joke -- An out of towner is asking folks at the cafe -- "who's the best doctor in town? O'Donnell... when he's sober". "ok, so who's the second best doctor in town? O'Donnell, when he's drunk". Substitute tired for drunk and it's the same point -- the doctor whose been there all night, and knows the patient, is still the better doctor than someone coming in fresh who doesn't know what's going on with this patient. Of course to a degree hand-offs could be better, but so far nobody knows a great way to do this without trying to give giant notebooks full of info on each patient, which simply results in more paperwork and too much reading material to be useful. The other alternative might be to have more residents and have them cover fewer patients -- that way learning what's going on with the patients might not be such a chore. But for the time being, in my mind, the safest thing for the patients is the fewest shift changes. Within reason.

 

[3dtp]

Speaking from personal experience, I'm a lot more dangerous to a patient when I don't know him/her because I've just been handed off a list of 40 patients and gotten maybe a sentence on each of them, largely consisting of "this person should be fine, there is nothing you really need to do for them tonight, just follow up on the labs", than I am at the end of a 30 hour shift. . . . But I feel like I have a fighting chance to give the right reflex answer at the end of the shift when somewhere in my groggy brain I know the patient.

The New York State Bell Commission found otherwise after a comprehensive investigation.

. . . Substitute tired for drunk and it's the same point -- the doctor whose been there all night, and knows the patient, is still the better doctor than someone coming in fresh who doesn't know what's going on with this patient. Of course to a degree hand-offs could be better, but so far nobody knows a great way to do this without trying to give giant notebooks full of info on each patient, which simply results in more paperwork and too much reading material to be useful. <snip>

You are correct. Acute on Chronic sleep deprivation is bad. It is as bad as doing your job while intoxicated, and perhaps much worse. With intoxication, you at least have a clue that you might be dangerously impaired. With chronic and acute on chronic sleep deprivation, much like a gradual hypoxia onset, you are much more likely to miss clear indications of serious impairment until it is too late. Ibid. NYS Bell Commission report.

As for complex patients who crash in the night, we do indeed have a book of information on these patients. It is called the medical record. A patient who is admitted prior to your acceptance of a handoff, usually has a rather comprehensive H&P, lab panels, pulmonary/cardiac and imaging studies either in hand or in process. In addition, they usually have old records which if needed can be quickly scanned for pertinent information. The fact that this is frequently undone, does not mean that the records don't exist. And in fact, for a peculiar problem in the middle of the night with a newly unstable patient, the old record may give you what you need to know to solve the problem and perhaps save a life. I seriously doubt if you are called to a newly unstable patient at hour 38 of your 40 hour shift, you will be eager to read the record. You just want to stay awake long enough to get out of there, do the minimum possible to pass on the patient before you pass out.

But for the time being, in my mind, the safest thing for the patients is the fewest shift changes. Within reason.

Within reason is the key. Above, exPCM cited programs that violate the law and residents with impunity. exPCM is correct. My internship institution switched from a somewhat unreasonable but survivable Q5/38-42 hour call schedule to Q3/Q4 40 hour call schedule and work weeks of 110 hours/week. The RRC long had rules limiting work weeks to the present ACGME rules, but they were never enforced. The ACGME 80/Q4/30 rules were well announced, with an enforcement date in the coming year to stave off John Conyer's legislation to mandate the rules nationwide. My institution and many others raised their collective middle finger at the ACGME, Congress and the Nation and went merrily about their business.

Hopkins and Yale got publically dinged for it. People who came after me were subject to the new ACGME rules at my training program. They were told to lie to the ACGME about their work hours and conditions. This is doubly inappropriate. The institutions are training residents that it is just fine to lie to governing bodies, insurance companies, CMS or state regulating bodies, which in many cases is a felony, if it serves your desires. I don't think this is what we want to be teaching our residents.


Human physiology, especially sleep hygiene is not a new science.

It is not about error free medicine on either side of the debate. Community teaching hospitals co-exist right along side community non-teaching hospitals and both do fine without attendings being in house awake and on their feet 90hrs/week.

It is about the money. You work for $11/hour. I guarantee you if someone declared tomorrow afternoon that all residents got paid $20/clock-hour on duty, and 1.5x for any hours over 40 hours/week (raising your erstwhile residents salary from $44k to $96k), there would be an influx of cheaper PA and RNPs faster than you can shake a stick at.

 

[Shosha]

Can any of you share what the resident shift overlap is at your particular institutions? In other words, how long are resident1 and resident2 at the hospital together at the end of resident1's shift and beginning of resident2's shift?

Thanks.

 

[Winged Scapula]

Can any of you share what the resident shift overlap is at your particular institutions? In other words, how long are resident1 and resident2 at the hospital together at the end of resident1's shift and beginning of resident2's shift?

Thanks.

Our residents didn't do shifts. They are all in house at the same time (ie, every one comes in in the morning, at various times depending on census, what time the Chief tells them to be there). When the day is over, the residents contact the resident who will be staying on call to do sign out. This is usually around 6 pm or so. It is not supposed to be any earlier than 5 pm for sign out.

The resident who isn't on call may either leave immediately after sign out or may hang around to finish up a few things. He/she may continue to take pages after sign out but transfer pages upon departure, or may sign out the pager at the time of paper sign out.

Programs with NF usually have some overlap.

 

[Law2Doc]

...
Programs with NF usually have some overlap.

It's usually 1/2 hour to an hour. Long enough to give a minimal sign out the 30-40 patients, and to let the outgoing resident finish up the one or two things s/he promised to get done before s/he left. Beyond that the outgoing resident runs a risk of running afoul of the hour restrictions, and defeats the purpose of night float. Generally it works something like this -- night float is supposed to arrive by, say, 6, and the outgoing resident is supposed to sign out and leave by, say, 7. If everything is wrapped up, the outgoing resident will sign out at 6 and be out the door by 6:20. If there's a lot of loose ends, the out going resident will try not to screw over the night float person that badly, and will generally work until about 7, and do an abbreviated sign out, getting out the door by 7:15. So in most cases the amount of overlap where the NF person can ask questions is pretty minimal, and not enough to obviate any concerns of handoff.

 

[Law2Doc]

...
As for complex patients who crash in the night, we do indeed have a book of information on these patients. It is called the medical record. A patient who is admitted prior to your acceptance of a handoff, usually has a rather comprehensive H&P, lab panels, pulmonary/cardiac and imaging studies either in hand or in process. In addition, they usually have old records which if needed can be quickly scanned for pertinent information. The fact that this is frequently undone, does not mean that the records don't exist. ..

Oh, the records exist -- that's not really the problem, but when time is of the essence, it is essentially useless. It's like trying to read a manual on how to fly an airplane when the airplane is already crashing. The manual can be fantastically detailed, but it still won't help the typical person. You need to already have that info in your head or the passenger/patient is SOL. The person who was dealing with this patient over the past 30 hours had the time to weed through the record and learn what is necessary, and more importantly knows exactly what happened over the past 30 hours. The poor dude who gets the abbreviated handoff right before that patient starts to crash won't have the time to dig through all the crap. The best approach is to find a way to get all the important info into a page or less. But when you have 30+ patients, even that ends up too much to weed through in many situations. So no, the medical record is nice to have, and you always do, but it's not a good response to the handoff concerns. If anything it adds to the reason handoffs are dangerous -- there's too much to know in too short a period of time.

 

[3dtp]

Oh, the records exist -- that's not really the problem, but when time is of the essence, it is essentially useless. It's like trying to read a manual on how to fly an airplane when the airplane is already crashing. The manual can be fantastically detailed, but it still won't help the typical person. You need to already have that info in your head or the passenger/patient is SOL. The person who was dealing with this patient over the past 30 hours had the time to weed through the record and learn what is necessary, and more importantly knows exactly what happened over the past 30 hours. The poor dude who gets the abbreviated handoff right before that patient starts to crash won't have the time to dig through all the crap. The best approach is to find a way to get all the important info into a page or less. But when you have 30+ patients, even that ends up too much to weed through in many situations. So no, the medical record is nice to have, and you always do, but it's not a good response to the handoff concerns. If anything it adds to the reason handoffs are dangerous -- there's too much to know in too short a period of time.

You don't read the manual when the airplane is already crashing. That would be the equivalent to reading Harrison's at a code. You fly the airplane. All pilots are taught this from the first day of flight school. You level the wings, maintain your airspeed and then, if there's time, you run the emergency checklist. Works for a Champ, or a 747. Just like you do with an unstable patient. You stick to the basics. The presumption is that you have a basic fund of knowledge to allow you to make an accurate, fast assessment, plan and execute.

If a patient starts to crash your job is to stop the crash (ie stabilize the patient).Same presumption: You are trained to deal with an emerging unstable patient and keep them alive until you can determine why they are unstable. This may be difficult and may not always work, but ABC. Patent airway, keep 'em breathing/oxygenated and keep the pump running. If they're leaking, stop it, and tank 'em up. Then deal with the developing crisis and its root causes. This scenario is no different than having an unstable patient come into the ED with no information. Likewise, if a patient signed out becomes unstable on your watch, you stabilize the patient, then and only then do you try to figure out what to do next to keep the patient stabilized (ie look at the pictures, check the labs, get new ones, read the manual).

If the ED can do 12 hour shift signouts on a room full of potentially unknown and potentially unstable patients, effectively and efficiently, as EDs have been doing for years, then it can be done on the floors in a less chaotic environment, with a good deal of information immediately available from floor staff (labs, ekgs, imaging, hematology).

 

[Publicola]

Sign out happens everywhere...even at residency programs without nightfloat. At the end of the 30 hour shift at my institution we sign out to our resident who then signs out to the cross cover intern. Every day all non-call teams sign out, so there are still handoffs and transfer of care in all systems. So when you are cross cover and get a call on a critical patient who is not on your team at hour 23 of your shift you are not only incredibly sleep deprived but also treating a patient you were handed off. I would rather treat patients handed off to me when I am at lest rested and thinking more clearly. I love how medicine tries to be so evidenced based for patients but will not police itself and stop people from seeing patients when they are impaired from sleep deprivation. I don't think we are doing the best for our patients when "I did long shifts so you should do them" blunt force reasoning prevails.

 

[Shosha]

Based on everything I have read here, and I have read it carefully, the only rational explanation for the current system appears to be economic. I fully acknowledge that my limited knowledge of the residency system and whatever I read on the internet are not sufficient for yielding a rigorous analysis, but I have yet to come across a convincing argument that is not rooted in economics.

Common sense dictates that if the problem is the "hand-off" process, which is only delayed but never eliminated by extra long shifts, then it is the "hand-off" process itself that needs to be fixed. The length of the residents' shifts is irrelevant to the issue of the "hand-off" and using the "hand-off" as the reason for long hours seems illogical. What if each resident only worked a maximum 20 hour shift and the "night float" person came in at hour 18, so that there would be a 2 hour overlap and a smoother, better orchestrated, more informative "hand-off"? Can anyone give a cogent argument for why this would not be good? And if it would be good, then what is the single factor which keeps this from happening? I believe it is money. Thoughts?

 

[3dtp]

Based on everything I have read here, and I have read it carefully, the only rational explanation for the current system appears to be economic. I fully acknowledge that my limited knowledge of the residency system and whatever I read on the internet are not sufficient for yielding a rigorous analysis, but I have yet to come across a convincing argument that is not rooted in economics.

Common sense dictates that if the problem is the "hand-off" process, which is only delayed but never eliminated by extra long shifts, then it is the "hand-off" process itself that needs to be fixed. The length of the residents' shifts is irrelevant to the issue of the "hand-off" and using the "hand-off" as the reason for long hours seems illogical. What if each resident only worked a maximum 20 hour shift and the "night float" person came in at hour 18, so that there would be a 2 hour overlap and a smoother, better orchestrated, more informative "hand-off"? Can anyone give a cogent argument for why this would not be good? And if it would be good, then what is the single factor which keeps this from happening? I believe it is money. Thoughts?

I don't think it started out as being rooted in economics, but it quickly evolved into one.

Consider the history of residency education. Dr. William Halsted, Surgeon-in-Chief of Johns Hopkins (and inventor of the Halsted Radical Mastectomy) did a lot of experimenting with nerve blocks for anesthesia using a new substance called cocaine. (ca. 1885). He tested it on himself and his medical students. Surgical residency under Dr. Halsted consisted of an "internship" of variable length, in which you were promoted to "resident" when he felt you ready, then later as "house surgeon." He demanded long hours of his interns/residents/house surgeons. In the course of his experimentation with cocaine, he became addicted to both cocaine and morphine, which some state clouded his judgement on the number of hours surgeons in training could reasonably work.

Hospitals later capitalized on this labor force, and in modern times has become quite institutionalized with the difficulty of physicians finding work absent completion of a residency. Gradually work hours and expectations have increased over the century. In essence, the origins of our system of medical training is based on the decision making ability of a skilled, but substance abusing surgeon.

When the ACGME announced it was serious with work hour restrictions in 2003, Duke University announced that they were going to create unregulated new "residencies" for Physician Assistants. They made no bones about it (there was an article in JAMA and the AMANews around that time). Their goal was to replace the estimated 55% reduction in FTE workforce that the ACGME was forcing on them by cutting residency hours to 80. Their published thought processes were as follows:
a. We will lose a substantial portion of labor which will have to be replaced.
b. We cannot afford to hire PA's at the going rate.
c. If we create a residency program for PAs, we can pay them less than the going rate and work them much longer, and thereby replace the residents at a lower cost.

I read this article and I was amazed at the unmitigated audacity. There was no attempt to disguise what was clearly a continuing scheme to obtain an alternate source of slaves to keep the mills running.

Fortunately, the PA organizations have largely fought this off, but this has not stopped others from jumping on the PA "residency" band wagon.

It is indeed nearly purely economic, in my opinion.

 

[DarthNeurology]

Common sense dictates that if the problem is the "hand-off" process, which is only delayed but never eliminated by extra long shifts, then it is the "hand-off" process itself that needs to be fixed. The length of the residents' shifts is irrelevant to the issue of the "hand-off" and using the "hand-off" as the reason for long hours seems illogical. What if each resident only worked a maximum 20 hour shift and the "night float" person came in at hour 18, so that there would be a 2 hour overlap and a smoother, better orchestrated, more informative "hand-off"? Can anyone give a cogent argument for why this would not be good? And if it would be good, then what is the single factor which keeps this from happening? I believe it is money. Thoughts?

It is not all economics, IMHO as many PDs and attendings want residents to work a certain number of hours per week for the clinical exposures AND when hours are reduced some residency programs are relying on computerized patient androids and extra-curricular learning to fill in what is lost. While residency programs do bring in some monies for hospitals, it is a drop in the bucket compared to what high priced admissions to ICU's and procedures charge.

While 45,000 a year for a resident sounds like a lot of money, it isn't compared to a total hospital budget, anyway medicare pays for it anyway. My point being that academic attendings would have a problem with IM residents doing 50 hour work weeks, and they would probably extended the residency period by one year or more . . . in the end the hospital would win by this scenario as they would have most likely more manhours of work and more residents all paid for by uncle sam.

You assume that giving two hours for hand-offs would make them less prone to errors. However, handouts that are two hours long would detract from patient care and residents would rush after this two hour period. Plus, most likely the extra time would be used by residents to eat dinner. Handouts are just bare-bones "what you need to watch out for" (at least in my experience) and often times the resident who gets the sign-off has to read the chart of a patient who is going downhill anyway. Two hours spent away from patient care also causes errors as when you in sign-off rounds you are not taking care of patients i.e. checking up on labs. . .

 

[unimaginative]

If the ED can do 12 hour shift signouts on a room full of potentially unknown and potentially unstable patients, effectively and efficiently, as EDs have been doing for years, then it can be done on the floors in a less chaotic environment, with a good deal of information immediately available from floor staff (labs, ekgs, imaging, hematology).

Who said they can? I would imagine that any real research done on ED handoffs is frightening. I don't think anyone could honestly argue that the ED does effective or efficient signouts from the perspective of patient care. I am always amazed how commonly the question, "what's this patients story" is followed by the answer, "I don't know anything about this patient except that they are admitted to medicine, they were signed out to me" follows. It seems the ED actually uses the occurence of signout as a valid excuse for knowing nothing about a patient.

Have you ever done an ED rotation and witnessed their signouts? They are cursory at best.

 

[Law2Doc]

Who said they can? I would imagine that any real research done on ED handoffs is frightening. I don't think anyone could honestly argue that the ED does effective or efficient signouts from the perspective of patient care. I am always amazed how commonly the question, "what's this patients story" is followed by the answer, "I don't know anything about this patient except that they are admitted to medicine, they were signed out to me" follows. It seems the ED actually uses the occurence of signout as a valid excuse for knowing nothing about a patient.

Have you ever done an ED rotation and witnessed their signouts? They are cursory at best.

Agree with this. I would also add that when a patient has been in the hospital a whole prior shift, it is inexcusable (and legally indefensible) for the next shift to know as little as the typical ED doc who gets handed off a patient who got there a few hours earlier. So no, you can't just get the ED quality hand off and use your basic "piloting skills" to handle any problem. Sure, that's what you do if you have to manage a crash without knowing much about the patient, but it's actually not acceptable medical care if the patient has been in the hospital for a while. The patient is better served if (1) the doctor taking care of them knows firsthand what has been going on for the past 20+ hours, or (2) the doctor has had time to pore over the medical record and see what has been going on for the past 20+ hours. So the fewer handoffs, the more likely one or both of these will have happened. If you are just going to wing it on the floor as if the patient is a new ED patient, then I suggest the patient is getting substandard care. And the only way to address this is (1) better, yet still concise handoffs (easier said than done), (2) fewer patients (so you have more time to read the record), or (3) fewer handoffs per day. Of these, the easiest and most realistic to implement is the third option. It unfortunately runs afoul of the notion that doctors need sleep. But as I mentioned above, a tired doctor who knows the patient and his/her hospital course is probably still better than an alert doctor who doesn't.

I personally don't like long shifts or sleep deprivation, although I am suffering through my share. But I have to say from personal experience/observation that there is some legitimate reason for it beyond the purely economic suggestions above. Patients are better off when the doctor who dealt with them the last X hours is still managing their care, and worse off any time somebody new is just starting their shift.

 

[Law2Doc]

...So when you are cross cover and get a call on a critical patient who is not on your team at hour 23 of your shift you are not only incredibly sleep deprived but also treating a patient you were handed off. ...

The point is that by hour 23, you should have had time to familiarize yourself with the patients and are no longer relying purely on the handoff info. By that point, you at a minimum know if the patient has issues in the past 23 hours and what you did about them. By contrast, the person who is fresh but has a patient start crashing shortly after sign out doesn't have this luxury. And the more handoffs you have per day, the more such occurrences you will have.

While I love my sleep, I would still rather have a patient start to crash later in my shift after I know who they are, and what I've had to do already to keep them out of trouble, rather than earlier in the shift when I know nothing but the handoff report that this patient "should be fine, nothing to do, just make sure the labs are ordered".

I think the cross covering you mentioned is a HUGE component of the problem -- at least if you are just covering your team's patients, you may have familiarity with the longer duration patients who are still there from the prior day. But when you are covering a group of unknowns AND you just took over, that compounds things.

 

[ANCAdoc]

The quality of handoffs may be overrated. When I get 20-40 patients at sign out I do not remember a single thing about them later. Call is just too busy to have all of those details in my head. I want to know: why are they here, are they stable, what issues do you think may come up.

95% of my pages are minor. The ones I need to see (SOB, CP) generally get worked up the same in most cases. I will look in the EMR to see if an etiology is obvious or if they have had this before. Point being, I look in the EMR if something goes south, of course after stabilizing the patient.

I'm in IM. Perhaps surgical fields are different.

 

[ThinkTooMuch]

Yes, I worked quite a few 36 hour shifts, often without sleep, during my prelim medicine year. I did not think it was humane and still don't.
If handoffs are so dangerous then why stop at 30 hours, why not 48 or 72 hour shifts?
The idea that academic med centers are better is not supported by evidence:
Hospitals where doctors receive training are generally thought of as the most advanced type of hospital. So, for the patient, is it best to be admitted to a 'teaching hospital'? A review of the evidence from international research has concluded that there is no strong evidence that patients in teaching hospitals do better - or worse - than those admitted to other hospitals.

http://www.medicalnewstoday.com/articles/51644.php

All of this BS that residents must suffer through long shifts without sleep to keep patients safe is ridiculous. The PD mantra is "the patient comes first". The implementation is that the resident is forced to work unhealthy and non-physiologic shifts. Hiring PAs to cover at night like some community hospitals do might cost money - however they don't want to do this at many teaching hospitals because it would cut into the bottom line.

Training programs routinely violate the law and abuse residents with no consequences.

During my internship, a colleague fell asleep at the wheel on the way home, as I often did secondary to my 90 to 105 hour work weeks. This time the colleague crossed the center line, had a head on collision, and ended up a quadriplegic.

Now I realize you probably don't give a flying leap about what happened to my colleague because it wasn't you. Many here will say that he is whining from his wheelchair. Why in the world did we become doctors in the first place? To abuse people?

I think human evolution has favored individuals who can best psychologically but preferably physically, undermine other individuals. Goal of this of course is to limit sexual competition. So yes, in the grand scheme of things everyone, doctors included, are out to "abuse".

 

[dragonfly99]

I agree with Darth.
I think that a big reason for working long hours is to get clinical exposure...I did it as a resident and I do it now, as a fellow.
But I think it was good that the 80 hour limit was put in place...it got rid of the Q2 overnight in house call, and it got rid of the worst work hours abuses, while still allowing for lots of time in house to see patients.
I had a minor car accident while a 4th year med student, and I know it was because I was way too tired, had been working 100 hours a week for just too long, and I just had no hand-eye coordination any more. It was a lucky thing that nobody was hurt.

 

[DarthNeurology]

The quality of handoffs may be overrated. When I get 20-40 patients at sign out I do not remember a single thing about them later. Call is just too busy to have all of those details in my head. I want to know: why are they here, are they stable, what issues do you think may come up.

95% of my pages are minor. The ones I need to see (SOB, CP) generally get worked up the same in most cases. I will look in the EMR to see if an etiology is obvious or if they have had this before. Point being, I look in the EMR if something goes south, of course after stabilizing the patient.

I'm in IM. Perhaps surgical fields are different.

Some surgical residents have to cover the SICU in between cases and they have to know their patient i.e. medhx, meds, pressors, almost everything. . . and this is on some 12 bed SICUs while also being sleep deprived and doing surgical OR cases.

 

[ANCAdoc]

Some surgical residents have to cover the SICU in between cases and they have to know their patient i.e. medhx, meds, pressors, almost everything. . . and this is on some 12 bed SICUs while also being sleep deprived and doing surgical OR cases.

I do think the quality of handoffs is much more impt for the SICU/MICU.

At one of our hospitals, we have one of the largest ICU's in the country, with >120 ICU beds spread among cardiology, neurosurgery, surgery, medicine. While an intern or resident is obviously not cross covering all of those, it is still quite a bit. Enough that relying on an EMR is vital. No one can remember that much stuff.

 

[Ttan]

Long ago pride was recognized as one of the seven deadly sins....

hahahahahahaahahahahahahaahahahhaha

 

[nope80]

80 hour limits are better than nothing but still 80 hours...thats a lot! You basically have sold your life off to the hospital. There's got to be a better way; i just think until we start to speak up and bring this issue to the forefront, nothing will ever change. I wonder how hospitals and med education are run in europe? I refuse to believe that they work like this in places like italy where family, relaxation, food and life quality are of paramount importance.

 

[michaelrack]

80 hour limits are better than nothing but still 80 hours...thats a lot! .

80 hrs a week of work plus 50 hours for sleep still leaves you 38 hours per week of free time.

 

[Ashers]

80 hour limits are better than nothing but still 80 hours...thats a lot! You basically have sold your life off to the hospital. There's got to be a better way; i just think until we start to speak up and bring this issue to the forefront, nothing will ever change. I wonder how hospitals and med education are run in europe? I refuse to believe that they work like this in places like italy where family, relaxation, food and life quality are of paramount importance.

Yeah, they don't. Here's a brief thing of the EU hours.

EUROPEAN COMMISSION
Brussels, 20 October 2009
Junior doctors and the Working Time Directive in the UK
What are the new rules?
· There are no new European Union rules on working time for doctors. The
existing Working Time Directive (which entered force in the UK in 1998)
states that a worker should not be required to work more than 48 hours per
week, on average, including any overtime.
· The rules have applied to doctors in training &#8211; as agreed by all EU
countries, including the UK &#8211; since 1 August 2004. The limit was phased in
over a five year period from 58 hours to the normal limit of 48 hours for
doctors in training (it has applied to other workers in the UK since 1998)
because they had specific work patterns which in some cases involved very
long working hours.
What is the current limit for junior doctors' working hours?
· On 2 October 2009, the European Commission agreed to a request from the
UK to extend working time for doctors in training to 52 hours (on average,
including on-call time at the workplace) on a temporary basis until 31 July
2011 (a further two years).
· The Working Time Directive also allows EU countries who have special
difficulties in meeting their responsibilities for organisation and delivery of
health services to extend the 52-hour limit for doctors in training for one final
year, until 31 July 2012. After that date, the 48-hour limit for average weekly
working time applies in full.

from here

When I graduated in May, I talked with one of my friends from England who's doing his anesthesia training. He graduated in 2004. I will be in practicing before he is. He said it'll take him 10 years of post-graduate training before he's able to practice on his own. Would I want to do residency for 10yrs even at 48hr/wk. Heck no. Am I working 80hrs or more? Sure am. I'm surviving, and I like sleep.

 

[nope80]

80 hrs a week of work plus 50 hours for sleep still leaves you 38 hours per week of free time.

8 hours a day for sleep = 4.5 hours a day. Thats for getting ready in the morning, cooking, eating, reading. Are you kidding me, thats nothing.

 

[Winged Scapula]

8 hours a day for sleep = 4.5 hours a day. Thats for getting ready in the morning, cooking, eating, reading. Are you kidding me, thats nothing.

How many hours a day do you think even people with non-medical jobs have to do this stuff? My father was up by 0600 every day, never home before 1800. He certainly didn't have copious hours to do much after work.

 

[smq123]

How many hours a day do you think even people with non-medical jobs have to do this stuff? My father was up by 0600 every day, never home before 1800. He certainly didn't have copious hours to do much after work.

Agreed.

There's a tech in our hospital who told me that it takes, roughly, 2.5 hours to get from her house to our hospital one way. That's because she can't afford a car and has to rely on mass transit (with multiple transfers). She leaves the house at 5 AM to get here by 8. She doesn't want to quit this job because the benefits are good and the economy is so unstable. She also works a part time job on the side to make ends meet, so she doesn't get home until 8 or 9 PM. She's a single mom, too, by the way. Makes me appreciate my life a lot more.

 

[exPCM]

8 hours a day for sleep = 4.5 hours a day. Thats for getting ready in the morning, cooking, eating, reading. Are you kidding me, thats nothing.

A lot of people in medicine are very accepting of being abused and boast about the long hours they have worked.
To make a point my father used to tell me that he walked 10 miles each way to school every day and it was uphill both ways and he had no shoes.
A lot of people in medicine make similar exaggerated claims of the hours they worked and the hurdles they have overcome.
However a tradition of abuse in residency does not mean that the abuse should be allowed to continue.